By the end of 1999, 156 Member States had an official national essential drugs list, and 127 of the lists had been updated in the previous five years. Most of these lists are linked to national clinical guidelines used for training and supervision. They also serve as a guide for drug supply in the public sector, drug benefits within reimbursement schemes, drug donations and local production. The concept of using fewer drugs more effectively therefore seems to be widespread, yet it is not always simple to implement fully, and various old and new challenges need to be considered.

Gaining further acceptance of the principle

There may be opposition to the use of the essential drugs list. Prescribers may see it as undermining their clinical freedom, while pharmacists may be worried about the financial implications. Manufacturers may fear that their market will be eroded, and consumers may think that they are being offered second-rate cheap drugs. If these concerns are not addressed, the concept of selection and the use of an essential drugs list will not be accepted. This is why the selection process should be consultative, and why informing and educating those affected is important.

Promoting essential drugs in the private sector

There has been considerable experience with the use of an essential drugs list in the public sector. However, in most low- and middle-income countries the majority of people are treated with drugs from the private sector, paid for out-of-pocket. Too often these consumers are prescribed or dispensed high-priced drugs, often in small quantities, rather than therapeutic amounts of essential drugs. Promotion of non-essential drugs often results in over-treatment of mild illnesses, inadequate treatment of serious illnesses, and overuse of antibiotics. Widespread prescription and sale of non-essential drugs means that households, especially poor households, are not getting the best health care value for their money and may ultimately not receive the treatment they need.

Promoting the essential drugs concept in the private sector continues to present countries with a considerable challenge. Private health insurance programmes and enlightened professional associations are often the best entry point for introducing cost-effective drug selection into the private sector.

Donations of non-essential drugs

The donation of non-essential drugs can undermine the acceptance and implementation of the selection process and adherence to evidence-based clinical guidelines. WHO, together with many other organizations, has developed interagency guidelines to address this issue.¹⁷ The key point in this respect is that drug donations should be limited to drugs on the national essential drugs list, unless specifically requested and agreed upon otherwise.